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Manual Lymphatic Drainage (MLD) Intake Form

Birthday
Month
Day
Year
Do you have any of the following?
Pregnancy C-Section
Yes
No
Do you currently or have you recently had any swelling?
Yes
No

The following questions are for those with a history of cancer. Please disregard if this doesn't apply to you and skip to the end and hit SUBMIT

Have you had any lymph nodes removed?
Yes
No
Have you been diagnosed with Lymphedema?
Yes
No
Do you use, or have you used any of the following to manage your swelling?
Have you had Chemotherapy?
Yes
No
Radiation
Yes
No
Date Completed Radiation
Month
Day
Year
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